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

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0295) with bedside rails (E0305) and an innerspring mattress (E0271).  You asked the Plan to pre-approve a semi-electric hospital bed with accessories. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.  The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:  1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  2. Requires attachments which can only be attached to a hospital bed; AND  3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  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 semi-electric hospital bed with accessories. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee's condition requires position of the body in ways not feasible in an ordinary bed. Records indicate the enrollee requires the head of the bed elevated up to 20 cm due to gastroesophageal reflux; records do not document that a wedge pillow would be inadequate for the enrollee's needs. There is no documentation that the enrollee requires frequent changes in body position or immediate changes in body position, or that the enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed.  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 semi-electric hospital bed with accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0295) with bedside rails (E0305) and an innerspring mattress (E0271).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says you are receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF).  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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. You appear to be nearing a plateau in function, and are not shown to be able to fully partake in daily skilled therapies. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial, and, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the C9orf72 expansion assay.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this test is not known to change treatment or outcomes patients with a diagnosis of 
frontotemporal dementia.

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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee is believed to have fronto-temporal dementia (FTD). This is a 
diagnosis/condition that is not readily reversible. The management of the condition is largely symptomatic and 
otherwise supportive in nature. In this context, it cannot be said that the provision of genetic testing would be 
expected to improve patient outcomes and/or change physician care and treatment of the enrollee. The 
requested genetic testing is also not necessarily diagnostic for FTD by itself (rather FTD can be diagnosed on a 
clinical basis alone. This genetic test is not otherwise specific for FTD). Given these limitations it cannot be 
said that the enrollee would meet the requirements of the applicable LCD for provision of this form of genetic 
testing.

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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the C9orf72 expansion assay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services (96365, 36415, 80048, 80076, 84443, 85025, G0463) provided June 17, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the OON medical services. You say that you feel the enrollee should continue care with her established provider. The Plan denied your request. The Plan says these services were not pre-approved and are not covered when provided OON. Additionally, the Plan says that code 84443 appears to be a duplicate billing. 

 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 medical services (96365, 36415, 80048, 80076, 84443, 85025, G0463) provided June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second opinion orthopedic consultation to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.  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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a second opinion orthopedic consultation to be rendered by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in the current hospital setting.  

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 30, 2021, to September 7, 2021. 
 You asked the Plan to waive the copayment the inpatient hospital care. You say that the services should be covered as you disagree with the copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 you must pay a $325 copayment for Inpatient hospital care.   
  
You have been asked to pay a $325 copayment per day for five days inpatient hospital care from August 30, 2021, to September 3, 2021 ($325 x 5 = $1,625). 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 copayment for inpatient hospital care provided from August 30, 2021, to September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve functional medicine care to be rendered by the OON provider.  

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.  

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve functional medicine care to be rendered by the OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight surgical extractions (D7210 x8) and an alveoloplasty in conjunction with extractions (D7311).  You asked the Plan to pre-approve the extractions and alveoloplasty. You say that you would like assistance from your insurance in covering the extraction of the remaining 8 teeth. The Plan denied your request. The Plan says your extraction benefit has been exhausted for the 2021 Plan year. The Plan also says that alveoloplasty is not a covered benefit under your 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, alveoloplasty in conjunction with extractions (D7311) is not among those covered under this benefit. The contract says that extraction is limited to 1 procedure per year. The record shows that you received approval for one extraction and your extraction benefit for the 2021 Plan year has been exhausted. Therefore, we decided that the Plan does not have to pre-approve eight surgical extractions (D7210 x8) and an alveoloplasty in conjunction with extractions (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this request is denied based on the information provided, as the criteria was not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stationary bike (A9300).  You asked the Plan to pre-approve the stationary bike. You say that the exercise bike is medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature and is non-covered.  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 a stationary bike (A9300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, E1002, E1028, E2359) 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 this is not medically necessary.  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 services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee is at high risk of a pressure ulcer, utilizes bladder catherization or has increased tone or spasticity. In summary, the enrollee does not meet criteria for a group 3 power wheelchair with a single power option and power tilt as requested but she may meet criteria for a group 3 power wheelchair with no power option.   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 a group 3 power wheelchair and accessories (K0856, E1002, E1028, E2359) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in other settings.  
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  

You asked the Plan to pre-approve the device. You say that the enrollee is an excellent candidate for this minimally invasive procedure. The Plan denied your request. The Plan says this is not considered medically necessary in the treatment of spinal stenosis.  

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 this device is experimental. More research is needed to show safety and efficacy.  
 
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 the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.