Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care services.
You asked the Plan to pre-approve home health care services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 home health care services. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the documentation doesn't support that you require additional skilled rehabilitation services to provide treatment that is medically necessary. You do not require additional skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You received skilled rehabilitation services with a resulting improvement in function and strength. The requested home health services are 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 home health care services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested service is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E377), expandable controller harness (E2313) and electronic connection (E2311).
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
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 these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The documentation does
not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your function in the upper extremities with the ability to feed yourself indicates that you can control any power options through their own individual switches. Our physician reviewer found that your condition does not meet criteria for coverage of these items. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E377), expandable controller harness (E2313) and electronic connection (E2311).
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not require transfer to LTACH.
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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine trips outside of the 60-mile radius.
You asked the Plan to pre-approve additional trips. You say that you only have 1 and a half round trips left. You say that you have appointments with your oncologist, liver doctor, and primary care physician. You say that you have started pain treatments recently too. You also say that you cannot afford to pay for transportation every time you have an appointment. The Plan denied your request. The Plan says you have used 21 of the 24 allowed trips. The Plan says that you have 3 trips remaining for 2021. The Plan also says that anything beyond the 24 allowed one-way trips is not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the file shows that you only have 3 one-way trips left for 2021. Additional trips beyond the allowed 24 one-way trips are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine trips outside of the 60-mile radius.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that screening CT colonography is non-covered. We looked at the file and Medicare rules. The services at issue are a screening CT colonography. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) colonography.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from February 16, 2021, to February 26, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this provider is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. The services at issue in this appeal were rendered by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for services provided from February 16, 2021, to February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, E1028, E2361, E0973) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is needed to help move around the house and assist when you go outside the house for grocery shopping and doctor's office appointments. The Plan denied
your request. The Plan says per the physical therapist's assessment, all activities of daily living can be performed independently.
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 the documentation does not reveal that the enrollee's mobility deficit impairs participation in MRADLs in the home. The documentation notes that the enrollee can walk 50 feet with an assistive device and is independent with MRADLs in the home. 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 power wheelchair and accessories (K0823, E1028, E2361, E0973) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a temporomandibular joint (TMJ) therapy evaluation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that other means of treatment have failed. The Plan denied your request. The Plan says the services are available from network providers.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a temporomandibular joint (TMJ) therapy evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued chiropractic manipulation.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain and segmental and somatic dysfunction of the spine. There is no documentation of improvement from previous chiropractic services. The documentation supports that continued chiropractic services would be considered maintenance therapy. Continued services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued chiropractic manipulation.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Accu-Chek blood sugar testing strips for the enrollee.
You asked the Plan to pre-approve these services. You say that these test strips are medically necessary. The Plan denied your request. The Plan says that that covered supplies are available for the enrollee.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. It is reasonable to provide strips that work with the Medtronic 770g system. This enhances rapid communication between the pump and the meter; using a different strip would be slower and negatively impact the enrollee diabetes mellitus control and care. Our physician reviewer found that these services are medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Accu-Chek blood sugar testing strips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are 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 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 indicates that the enrollee does not treating with insulin three or more times per day or using an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are 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 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 indicates that the enrollee does not treat with three or more injections of insulin per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care hospital.
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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve myocardial perfusion imaging to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 22, 2021.
You asked the Plan to pay for the transportation service. You say that there was no ambulance sent to your address on this date. You say that you should not have to pay for this claim as it is false and did not happen. The Plan denied your request. The Plan says no transport was provided. The Plan also says that no payment can be made if there was no transport provided.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 22, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the opium belladonna (A9270) provided in an outpatient setting on April 22, 2021.
You asked the Plan to pay for the self-administered drug. You say that you have no knowledge of receiving any self-administered drugs. You say that you were not informed in advance that you would receive a service that would not be Medicare covered. You also say that you do not believe you are responsible for this charge. The Plan denied your request. The Plan says the medication you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the medication you received is not covered under Medicare Part B.
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 pay for the opium belladonna (A9270) provided in an outpatient setting on April 22, 2021.
Benefits for the self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 26, 2021 to February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care prior to the authorization date issued by the Plan.
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 physician services provided on January 26, 2021 to February 25, 2021 by an out-of-network (OON) provider.