Persius/hicric huggingface dataset:
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 you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires services at the LTACH that are not available at the current acute care hospital where the enrollee is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality.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 self-administered drugs are not covered.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 pre-approve Emgality.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemethotrexate for the enrollee.You asked the Plan to pre-approvemethotrexate. You say that this is medically necessary.The Plan denied your request. The Plan says that this does not meet the Medicare criteria to be covered under the enrollee's Medicare Part B benefit.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 pre-approvemethotrexate for the enrollee.Benefits for methotrexatemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revision of a total shoulder arthroplasty (23474) provided on August 7, 2019.You asked the Plan to pay for the revision of a total shoulder arthroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records did not include documentation of a revision of total shoulder arthroplasty including allograft when performed; humeral and glenoid component.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 23474 is revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component. We asked our coder 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 revision of a total shoulder arthroplasty. Our reviewer says that 23474 does not meet criteria for billing or reimbursement. Our reviewer found the medical records provided do not have documentation of a Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component, therefore the service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the revision of a total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for revision of a total shoulder arthroplasty (23474) provided on August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that you are unable to get out of bed without assistance.The Plandenied your request. The Plansaysthis 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 above 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 correctin denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan .You asked the Plan to pay forechocardiography services. You say that this was medically necessary.The Plan denied your request. The Plan says this was not authorized.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 forthe echocardiography services (C8929 and Q9957) provided on July 25, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system.
You asked the Plan to pre-approve the power seat elevation system (E2300). You say that you need the power wheelchair accessories. The Plan denied your request. The Plan says the power seat elevation system is not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature and is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system.
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the member's needs are being met in the current setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metronidazole topical gel.You asked the Plan to pre-approve Metrogel. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D  prescription drug plan.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 pre-approve Metronidazole topical gel.Benefits for Metrogelmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Praluent auto-injector pen for the enrollee.You asked the Plan to pre-approvethe Praluent auto-injector pen. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under 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 pre-approvethe Praluent auto-injector pen for the enrollee.Benefits for the Praluent auto-injector penmay be available under Medicare Part D.Contactthe 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 physician's services provided on September 23, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure oral nutritional formula.
You asked the Plan to pre-approve Ensure. You say that this supplements for the food you are not able to eat. The Plan denied your request. The Plan says that there is no indication you use a feeding tube.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve Ensure oral nutritional formula.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT Scan of the head and brain (70470).
You asked the Plan to pre-approve the CT Scan. You say that the pain is getting worse and your doctor requested the CT Scan. The Plan denied your request. The Plan says that you do not meet coverage criteria for the CT Scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT Scan. Our reviewer says that you have intermittent persistent headaches of about 2-months' duration associated with intermittent numbness in arm and leg. Your provider has stated concern for intracranial process such as a subacute bleeding injury or space occupying lesion. Our physician reviewer found the CT Scan is 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 of the CT Scan have been met. Therefore, we decided that the Plan has to pre-approve a CT Scan of the head and brain (70470).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of platelet-rich plasma.
You asked the Plan to pre-approve platelet-rich plasma injection. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for the requested service is correct, because this platelet-rich plasma injection is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that injections of platelet-rich plasma with procedure code 0232T are not considered medically necessary and are not covered by Medicare at this time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of platelet-rich plasma injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an injection of platelet-rich plasma.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed with any type side rails, with mattress (E0260).
You asked the Plan to pre-approve the hospital bed. You say that you are appealing because you need this bed. The Plan denied your request. The Plan says the requested service has been found not medically necessary.
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 hospital bed. Our reviewer says that this enrollee does not meet the criteria for the semi-electric hospital bed. Our physician reviewer found the records indicates an ordinary bed with pillows is not adequate for her needed head elevation. The provided records do not document a need for frequent or immediate changes in body position. The provided records do not document a need for special attachments that cannot be fixed and used on an ordinary bed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed with any type side rails, with mattress (E0260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9328) provided to the enrollee from August 29, 2019, to September 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a valid code.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 pay for the services (S9328) provided to the enrollee from August 29, 2019, to September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha 140 MG/ML Sureclick.
You asked the Plan to pre-approve Repatha. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Repatha is not covered under your Medicare Part B benefit.
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 pre-approve Repatha 140 MG/ML Sureclick.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve a second opinion. You say that you would like to have a second opinion related to lung and bone cancer. The Plan denied your request. The Plan says there are in-network providers available for a second opinion.
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 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. 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 the medical services to be provided by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 12, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99190 is Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient during these services. Medicare does not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital. Payment for these services are included in the DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 12, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve knee arthroscopy (29881). You asked the Plan to pre-approve the knee arthroscopy. You say that the member has exceeded the 6-week burden of conservative care and their overall health is being jeopardized. The Plan denied your request. The Plan says that the member does not meet coverage criteria for the surgery.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the knee arthroscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member has failed to improve despite reasonable and/or comprehensive conservative treatment, including activity modification, NSAIDs, physical therapy, home exercise program, and corticosteroid injection. There is significant persistent and function-limiting right knee pain with associated buckling and giving way that places her at increased risk for fall/injury. There is evidence of mild to moderate osteoarthritis.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 knee arthroscopy have been met. Therefore, we decided that the Plan has to pre-approve knee arthroscopy (29881).