Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the medical records provided support the need for an inpatient level of care. The Plan denied your request. The Plan says that the criteria for coverage of inpatient care have not been met and that an admission is not medically necessary. The Plan says that an observation level of care is appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is an elderly female with evidence of lactic acidosis. The enrollee's lactate level fell during her hospital stay and she was at very high risk for complication. The enrollee developed atrial fibrillation with rapid ventricular rate during her stay. Due to the need or intravenous antibiotics with the diagnosis of the presence of mild lactic acidosis on admission, it was reasonable for the provider to expect the enrollee to need a stay of 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for acute inpatient hospital care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle libre (A9276).
You asked the Plan to pre-approve a Freestyle libre. You say that the item is necessary. The Plan denied your request. The Plan says the A code requested is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. Specifically, the A code is not a covered benefit. The Plan agreed to cover the supplies using the correct codes of K0553/K0554. Based on this information, we decided that Medicare rules for coverage of a Freestyle libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle libre (A9276).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily physician visits, nursing care, and intensive therapies to regain the ability to perform activities of daily living. The Plan denied your request. The Plan says the enrollee does not require an intensive, multi-disciplinary team approach to therapy, or close physician monitoring.
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 physician reviewer found that the enrollee's current level of function is ambulating 200 feet with a rolling walker with contact guard assist, transfers with standby assist, minimal assist with toilet transfers, and sit to stand with contact guard assist. The patient is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week or acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 was admitted to the hospital on February 9, 2020 with severe major depressive disorder with psychotic features. It is not expected that she will improve in a reasonable period of time, as she is not showing suicidal or homicidal ideation. She denies auditory and visual hallucinations. She is compliant with treatment and is showing no agitation or aggression. It does not appear that active treatment is taking place. The services are not reasonably expected to improve the enrollee's condition or be for the purposes of diagnosis and 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 inpatient psychiatric services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia (denosumab).
You asked the Plan to pre-approve Prolia. You say that despite previous treatments with oral bisphosphonates and Forteo the enrollee continues to have osteoporosis. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires that the enrollee try oral bisphosphonates and Zoledronic Acid before they will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of oral bisphosphonates and Zoledronic Acid. The documentation does not support that these drugs would likely be less effective and/or have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia (denosumab).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories from provider.You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that the enrollee can safely operate a Group 3 power wheelchair.The Plan denied your request. The Plan says there is no indication in the medical record that the member is capable of operating the requested power wheelchair independently.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the enrollee 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. The file does not show that the enrollee can safely operate the PMD being requested.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories from provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an ultrasound. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.
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 has network providers available who can provide 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 an ultrasound provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora right knee orthosis (L1833-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1833-LT), a left suspension sleeve (L2397-LT), a left knee control condylar pad (L2810-LT) and a right knee control condylar pad (L2810-RT) provided to the enrollee on October 22, 2018.You asked the Plan to pay forthe bilateral knee orthoses and accessory items. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not substantiate that the services are necessary for treatment of the enrollee's condition.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the bilateral knee orthoses and accessory items. Our reviewer says that the documentation does not support that the enrollee meets criteria for the orthoses ordered. Our physician reviewer found the enrollee was seen September 19, 2018 to establish care. There is insufficient documentation of a physical examination of the knees, and there is no documentation of any imaging of the knees. The enrollee did not complain of knee pain specifically, and there is no mention of bracing in the plan of care. The documentation in the case file does not support that the requested bilateral knee orthoses and accessory items were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the knees wouldreasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the bilateral knee orthoses and accessory items were medically reasonable and necessary in this case, as there is insufficient documentation of a physical examination of the knees.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 bilateral knee orthoses and accessory items have not been met.Therefore, we decided that the Plan does not have to pay fora right knee orthosis (L1833-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1833-LT), a left suspension sleeve (L2397-LT), a left knee control condylar pad (L2810-LT) and a right knee control condylar pad (L2810-RT) provided to the enrollee on October 22, 2018.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve . We decided that the Plan does not have to pre-approve .
You asked the Plan to pre-approve . The Plan says that the requested procedures are more than what is covered by the plan.
We decided that the Plan has to pre-approve 4 injections.
The Plan follows Medicare rules. Medicare rules say that lumbar joint injections are only covered under certain medical indications. The file shows that 3 bilateral levels of lumbar injections (CPT Code 64493, 64494, and 64495) were requested for 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 injections.
Our physician reviewer found that the enrollee has chronic low back pain with neurogenic claudication. The request is for 3 levels bilaterally. However, the coverage criteria have a utilization limit of 2 levels bilaterally. The request for 6 is over-utilization. Therefore, only 4 joints are medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pre-approve 4 injections.
We also decided that the Plan does not have to pre-approve 2 injections.
Our physician reviewer found that the coverage criteria have a utilization limit of 2 levels bilaterally. The request for 6 is over-utilization. Only 4 joints are medically reasonable and necessary. Therefore, the remaining 2 requested injections are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin (Q4121) and the associated application of the product (15275).
You asked the Plan to pre-approve TheraSkin (Q4121) and the associated application of the product (15275). You say that the requested TheraSkin is medically necessary. The Plan denied your request. The Plan says the requested TheraSkin is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve TheraSkin (Q4121) and the associated application of the product (15275). Our reviewer says that the requested TheraSkin is not medically necessary. Our physician reviewer found the requested TheraSkin is not medically reasonable or necessary for the enrollee in this case. TheraSkin is a biologically active, cryopreserved human skin allograft with both epidermis and dermis layers. Its cellular and extracellular composition provides a supply of growth factors, cytokines and collagen to promote wound healing. It is recommended for use in diabetic foot ulcerations and venous stasis ulcerations. In this particular case, the enrollee does not have a diagnosis of either a diabetic foot ulceration and or a venous stasis ulceration. Furthermore, the progress notes advised that this enrollee is suffering with infection to the ulceration, which is a contraindication for graft application. There is no documentation of basic wound care, including offloading to the ulcerative area as well as routine and aggressive debridement of nonviable tissue at the ulcer site. Medicare guidelines advised that Medicare will pay for services that are used to treat and/or improve the functioning of a malformed body member. An ulceration certainly meets this criteria. However, TheraSkin is not authorized for the use of a non-diabetic and or non-venous stasis ulceration. Furthermore, Medicare guidelines advise that a treatment must be appropriate and furnished in accordance with the accepted standards of medical practice for the diagnosis or treatment of the patient's condition. In this particular case, the ulceration is noted to be infected, and not a diabetic foot ulceration or venous stasis ulceration. Therefore, the requested TheraSkin allograft application is not medically reasonable or necessary for this enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin (Q4121) and the associated application of the product (15275) have not been met. Therefore, we decided that the Plan does not have to pre-approve TheraSkin (Q4121) and the associated application of the product (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital clinic visit provided on October 7, 2019.
You asked the Plan to waive the copayment for the hospital clinic visit. You say that you went in for a routine knee injection and your doctor asked about a bruise. You say the doctor looked at the bruise and referred you to your primary care doctor. You say there should be not charged because no services were rendered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $35 copayment for specialist for each in-network outpatient clinic visit. You have been asked to pay a $35 copayment for the hospital clinic visit. The hospital clinic visit falls within the "Outpatient hospital services" benefit category. The record shows the doctor addressed the bruise which is considered separate from the injection.
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 the hospital clinic visit provided on October 7, 2019.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
a heart attack and osteomyelitis of the foot. The enrollee is not intubated/ventilated. As LTACHs and ACHs are
licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The
enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 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: Favorable

We decided that the Plan has to pay for the ambulance services provided to the enrollee on July 31, 2019.
You asked the Plan to pay for the ambulance services. You say that this was medically necessary. The Plan denied your request. The Plan says that that this transport was not authorized.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says that the ambulance services were medically reasonable and necessary for the enrollee in this case. The documentation does support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. The enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport. The enrollee was being transferred to a hospital with a higher level of care (ICU) for ongoing management of sepsis and newly diagnosed atrial fibrillation. She was receiving intravenous fluids, amiodarone drip and intravenous magnesium. ALS level care was medically necessary. Our physician reviewer found that the enrollee's condition met Medicare criteria for coverage of ambulance 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 ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services provided to the enrollee on July 31, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRituxan for the enrollee.You asked the Plan to pre-approveRituxan. The Plan denied your request. The Plan says the use of Rituxan is not supported for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show the requested drug is medically necessary for the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approveRituxan for the enrollee.