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

We decided that the Plan does not have to pre-approve an ankle-foot orthosis walking boot (L4631).
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your
request. The Plan says the doctor did not send more clinical information about this request.
The Plan must follow Medicare rules. Medicare rules say that for custom-fabricated orthoses such as L4631,
there must be detailed documentation in the treating practitioner's records to support the medical necessity of
custom fabricated rather than a prefabricated orthosis.
The provider did not send in any records, despite requests, to corroborate the need for this orthosis. Based on
this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we
decided that the Plan does not have to pre-approve an ankle-foot orthosis walking boot (L4631).
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 stay is medically necessary. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting. The Plan states the services you require are called custodial care. The Plan states custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and eating. The Plan states custodial care is not a covered benefit under Medicare or the health plan.

The Plan states your doctor says you have contractures of your arms and legs, you do not require daily skilled therapy services, although could possibly benefit from outpatient therapy on an intermittent basis, or treatment under a restorative program and this therapy can safely be received at a different setting, for example, outpatient therapy in residential long-term care.

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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are not shown to be able to participate in daily skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 requested device. You say that the enrollee gets unexpected low blood
sugars. The Plan denied your request. The Plan says the enrollee does not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin
with at least three daily injections or requires 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 requested
device 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 sensor (A9276).
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered precautionary, and therefore not covered.
The Plan must follow Medicare rules. The rules say that Healthcare Common Procedure Coding System
(HCPCS) A9276 is not a covered code.
A sensor coded with A9276 is statutorily not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have
to pre-approve a sensor (A9276)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed rails for a commercial bed.
You asked the Plan to pre-approve bed rails for a commercial bed. You say that bed rails are necessary for safety. The Plan denied your request. The Plan says bed rails for a traditional bed are not covered.
The Plan covers all items that Medicare covers. Medicare does not cover grab bars. Medicare only covers side rails for hospital beds. While these items may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve bed rails for a commercial bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an heel stabilizer (L3170) and an ankle-foot orthosis (L1971) provided to the enrollee on February 18, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an heel stabilizer (L3170) and an ankle-foot orthosis (L1971) provided to the enrollee on February 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 10 to June
7, 2021.
You asked the Plan to pay for psychotherapy services. You say that you were told by a representative of the
Plan prior to services that the services at issue would be covered. The Plan denied your request. The Plan says
rules for payment have not been met because the provider of the services at issue is not enrolled in the
Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837)
provided on May 10 to June 7, 2021.
Your complaint about receiving erroneous or incomplete information about your benefits from a representative
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another 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 above.
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 enrollee was medically stable with no evidence of need for supervision by PMR
Physician or needs acute rehab nursing care. Functionally, given her current level, she does not require IRF
level of therapies. The enrollee may benefit from further PT and an OT but does not require an intensive
therapy program. IRF admission is not medically necessary based on the enrollee's current functional status
and lack of medical complexity.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 6 additional acupuncture visits.

You asked the Plan to pre-approve the additional acupuncture visits. You say that you are still unable to walk to the mailbox or prepare a meal for your family without having to stop and sit down. Please allow you to continue with acupuncture treatments until Tylenol is enough to relieve your pain. The Plan denied your request. The Plan says 6 acupuncture treatments have been approved. The Plan needs to know your response to care before more treatment can be considered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

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 additional acupuncture visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the medical records indicate the enrollee has reached maximum benefit from acupuncture treatments. The enrollee has shown no lasting benefit from on-going acupuncture treatments. The need for further treatments is not supported. The records do not show that the enrollee meets the criteria for Medicare coverage. 

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 additional acupuncture visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 6 additional acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve a manual wheelchair. You say that you are unable to use your power wheelchair in the home due to its size. The Plan denied your request. The Plan says Medicare does not cover duplicate equipment for use in the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have power wheelchair. A power wheelchair serves the same purpose as a manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
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 lives alone and is at supervision level. The Plan denied your request. The Plan says the enrollee's records do not show the enrollee does not require skilled nursing services or skilled rehabilitation services on a daily basis and which can only be provided on an inpatient basis in a SNF. The Plan states the enrollee's rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by the enrollee's health plan.

The Plan states the enrollee's rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.

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 the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 an IRF level of care is medically necessary. The Plan
denied your request. The Plan says the criteria for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee was medically stable with no evidence of need for supervision by a
physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care.
Functionally, while the enrollee needs physical therapy and occupational therapy, the enrollee does not require
IRF level of therapies given her current level. The enrollee may benefit from further physical therapy and
occupational therapy, but does not require an intensive therapy program. IRF admission is not medically
necessary based on the enrollee's lack of medical complexity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Dexcom CGM. You say that the FreeStyle Libre sensors sometimes fall
off the enrollee's arm. The Plan denied your request. The Plan says the enrollee received the FreeStyle Libre in
December of 2019.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a FreeStyle Libre CGM. A FreeStyle Libre CGM serves the same purpose
as a Dexcom CGM. The submitted medical records do not include documentation of why this does not meet the
enrollee's needs. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care, such as a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. Functionally, the enrollee needs physical therapy and occupational therapy, but given her current level with fatigue she does not require IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status to endure IRF therapies and lack of medical complexity. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy visits.
You asked the Plan to pre-approve additional services. You say that the enrollee continues to be at high risk for
falls. The Plan denied your request. The Plan says the enrollee has improved, and had no back pain during last
PT session.
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 additional services. Our physician
reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the
enrollee's condition. The records do not indicate his current functional level of ambulating 100 feet x 2 requires
the unique skills of a professional therapist to safely and effectively provide treatment. The therapy
reassessment appeal notes the enrollee was lethargic and closed his eyes in therapy. The cause of lethargy is not
clear, and may be adding to his falls. The requested services do not need to be performed only by a therapist, or
under the supervision of a therapist. The enrollee and caregiver were instructed in a home exercise program.
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design,
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further dete rioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care (ex. home with services, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.