Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 52 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 you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says these items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the semi-electric hospital bed is
medically necessary. The Plan denied your request. The Plan says the documentation does not reflect the
necessity.
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 the semi-electric hospital bed. Our
reviewer says that the service is not medically necessary. Our physician reviewer found while the
documentation shows the enrollee's condition requires position of the body in ways not feasible in an ordinary
bed, it is inconsistently documented as to the need for frequent changes in body position or immediate changes
in body position. There is no documentation that the patient's condition requires special attachments that cannot
be fixed and used on an ordinary bed.
Based on the medical records provided there is documentation that the patient requires a fixed or variable
height hospital bed but contemporaneous medical records from the time of the initial request for the semielectric
hospital bed do not clearly establish the need for frequent or immediate changes in body position to
qualify for a semi-electric hospital 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 the semi-electric hospital bed have
not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Euflexxa. Our reviewer says that the documentation does not support that step therapy criteria have been met for the requested drug. Our physician reviewer found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's additional required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC), group 2 heavy duty, 
captain's chair, patient weight capacity 301 to 450 pounds (K0825). 
 
You asked the Plan to pre-approve a group 2 PWC. You say that the PWC is medically necessary for this 
enrollee. Plan denied your request. The Plan says the PWC you are requesting does not meet the requirements 
for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 PWC (K0820, K0821, K0822, K0823, 
K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria described in the LCD 
for a PWC are met and the wheelchair is appropriate for the beneficiary's weight. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 power wheelchair. Our 
reviewer says that a group 2 PWC is not medically necessary. Our physician reviewer found that in this case, 
the request is for a heavy duty PWC with the capacity for 301-450 pounds. The documentation indicates that 
the enrollee weighs less than 300 pounds, therefore the requested PWC 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 a group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair (PWC), group 2 heavy duty, captain's chair, patient 
weight capacity 301 to 450 pounds (K0825).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block.
You asked the Plan to pre-approve a medial branch block. You say that the requested medial branch block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested medial branch block.
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 a medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested medial branch block. Our physician reviewer found the enrollee has chronic neck pain. The enrollee underwent bilateral Medial branch blocks (MBBs) and the pain went from 9/10 to 4/10. The request is for a second set of diagnostic MBBs. The enrollee did not achieve 80% pain relief from the first diagnostic block. Therefore, the request is deemed not medically reasonable or 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 a medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve a medial branch block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0007). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the manual wheelchair is medically 
necessary. The Plan denied your request. The Plan says the enrollee is already using a power wheelchair. A 
backup manual wheelchair is not covered. 
 
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 a power wheelchair. The power wheelchair serves the same purpose as the manual 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair 
(K0007).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second consultation with an out-of-network provider.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says the requested provider is not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 provider in
this case is not a network provider with the Plan. The Plan has network providers available who can provide the
services at issue in this appeal. We found no exception that would require the Plan to pre-approve these
services. Therefore, we decided that the Plan does not have to pre-approve a second consultation with an outof-
network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from June 11, 2020, to June 18, 2020,
and billed with DRG (diagnosis related group) 689.
You asked the Plan to pay for inpatient care. You say that the billed DRG was correct. The Plan denied your
request. The Plan says the records do not support the diagnosis of encephalopathy.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 689, kidney and urinary tract infections with
major complications or comorbidities, and a secondary diagnosis of G92, toxic encephalopathy. 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 inpatient care. Our reviewer says that the billed DRG is not
supported in the records. Our physician reviewer found although toxic encephalopathy is noted in the progress
notes and discharge summary, supporting medical record documentation was not found within the record.
While the enrollee's presentation warranted consideration of toxic encephalopathy, there is no documentation
of neurological exams consistent with a diagnosis of encephalopathy or diagnostic work ups done.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided from June 11, 2020, to June 18, 2020, and billed with DRG (diagnosis related
group) 689.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 20 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 you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional speech therapy sessions.
You asked the Plan to pre-approve 8 additional speech therapy sessions. You say that the 8 additional speech therapy sessions are medically necessary. The Plan denied your request. The Plan says the 8 additional speech therapy sessions are not medically necessary.
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 8 additional speech therapy sessions. 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The enrollee is full feed at mealtimes and assisted by CNAs and his speech/swallowing needs do not require ongoing skilled therapy. 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 the enrollee's 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 8 additional speech therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional speech therapy sessions.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits (CPT code G0299 X 5), for the enrollee.
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 home health skilled nursing visits. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 the home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits (CPT code G0299 X 5), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for frequent falls and infections of 
wounds of the legs. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of a Superion InterSpinous Spacer device (22869).
You asked the Plan to pre-approve the placement of a Superion InterSpinous Spacer device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
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 placement of a Superion InterSpinous Spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found accepted contraindications to the Superion InterSpinous Spacer device include the diagnosis of severe osteoporosis. Imaging included in the medical record demonstrated diffuse fatty marrow replacement due to osteoporosis, and there is no documentation to show that the enrollee does not have severe osteoporosis. 
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 placement of a Superion InterSpinous Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the placement of a Superion InterSpinous Spacer device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant placement (D6010) by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an implant placement. You say that you have a huge problem with your
tooth and your teeth hurt when you are eating. You also say the Plan is covering the extraction of your tooth,
but the provider says that the implant is necessary. You would like approval to receive an implant prior to
removing the tooth. The Plan denied your request. The Plan says this service is not covered under 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
implant placement (D6010) by an out-of-network (OON) provider.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for deep vein thrombosis after
recent spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.