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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to get back to normal function. The Plan denied your request. The Plan says the enrollee does not require an intensive, multi-disciplinary team approach to care.
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 was admitted to an acute hospital after a fall at home. The enrollee is requiring maximum assistance for transfers and activities of daily living. Based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy, but does not require treatment in an intensive rehabilitation therapy program. There is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to the enrollee's cognitive decline. Therefore, the requested services are 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 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: 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 enrollee clearly meets the LTACH admission criteria. 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 current acute care hospital is able to provide all of the services the enrollee requires. Continued care in the current acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to heal from back surgery. The Plan denied your request. The Plan says there are no medical issues that would require supervision by an inpatient rehab physician.
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 based on the limited medical records provided, the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment in an intensive rehabilitation therapy program. There is no documentation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe SNF stay provided from October 2, 2017 through October 15, 2017.You asked the Plan to pay forthe SNF stay. You say that the enrollee is dual eligible. You say that the claim should be reconsidered.The Plan denied your request. The Plan says Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe SNF stay provided from October 2, 2017 through October 15, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that require an IRF level of care. In this case, the enrollee is mostly standby assist for functional transfers and ADL's and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.Medicare coverage criteria for IRF care are not met. 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (67028).
You asked the Plan to pay for intravitreal injection of a pharmacologic agent. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records did not include documentation that an intravitreal injection of a pharmacologic agent was administered.
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 67028 is intravitreal injection of a pharmacologic agent (separate procedure). 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 intravitreal injection of a pharmacologic agent. Our reviewer says that the documentation does not support the billing of CPT 67028. Our reviewer found no clear and separate procedure note of an injection is noted. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intravitreal injection of a pharmacologic agent have not been met. Therefore, we decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (67028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next EZ test strips (A4253).
You asked the Plan to pre-approve Contour Next EZ test strips (A4253). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says they have approved a 3 month supply with no refills for the requested Contour Next EZ test strips to help transition to a preferred brand covered by the Plan.
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, Contour Next EZ test strips are medically necessary. Based on this information, we decided that Medicare rules for coverage of Contour Next EZ test strips (A4253) have not been met.Therefore, we decided that the Plan does not have to pre-approve Contour Next EZ test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve additional RFA (64635 and 64636).You asked the Plan to pre-approve the RFA. You say that you would like reconsideration as the service is medically necessary. The Plan denied your request. The Plan says the records do not show that the member experienced 50% pain relief for the last blocks that lasted 6 months.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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in thiscase. Our physician reviewer found the member's pain relief from the prior RFA did not last 6 months.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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve additional RFA (64635 and 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation from an out-of-network provider.
You asked the Plan to pre-approve the requested services. You say that your previous work was left incomplete. The Plan denied your request. The Plan says you must use providers that are in the network for all of your services.
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.
We looked at the file, and Medicare rules. The requested provider is not a contract provider with the plan. The Plan has dental providers who can provide services covered under your plan. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental consultation from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the medical records should support the necessity of the services in dispute. The Plan denied your request. The Plan says the request for a hospital bed is 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 a semi-electric hospital bed. Our reviewer says that the enrollee does not meet the criteria for coverage of the requested semi-electric hospital bed. Our physician reviewer found the records do not support the patient's condition require position of the body in ways not feasible in an ordinary bed, the patient requires frequent changes in body position and there is a need for immediate changes in body position, or the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. The records do not support the semi-electric hospital bed is 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 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 (E0260).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio IV 600 mg every four (4) weeks.
You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The Plan denied your request. The Plan says that the requested Entyvio is not medically necessary.
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 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 Entyvio. Our reviewer says that the requested Entyvio is medically necessary. Our physician reviewer found the enrollee has a diagnosis of Crohn's disease, unspecified. The enrollee underwent colectomy with ileocecal anastamosis. His course has been complicated by fistula formation. Entyvio was initiated at every 8 week intervals, and the enrollee had an excellent response. The enrollee has been becoming symptomatic 1-2 weeks prior to his 8 week infusion each cycle, and a serum drug level recently was low. Every 4 week dosing has been requested. The documentation supports that more frequent dosing is medically reasonable and necessary for the enrollee in this case, given his symptom pattern. The medical literature supports that increasing the dosing of Entyvio from every 8 weeks to every 4 weeks may improve outcomes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have been met. Therefore, we decided that the Plan has to pre-approve Entyvio IV 600 mg every four (4) weeks.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60mg/3ml syringe of Durolane (J7318).You asked the Plan to pre-approve the Durolane. You say that the Durolaneis medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet step therapy exception 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 todetermine if the Plan was correct in denying the request to pre-approve the Durolane. Our reviewer says that the member has not tried and failed treatment with Orthovisc. Our physician reviewer found the documentation does not support that Orthovisc wouldlikely be less effective, and/or would likely have adverse effects.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 Durolane have not been met. Therefore,we decided that the Plan does not have to pre-approve 60mg/3ml syringe of Durolane (J7318).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 10061) provided to the enrollee on June 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPTcode.In this case, the CPT Code Manual definition of code 10061 is "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple".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 services. Our reviewer says that the use of CPT code 10061 is not supported by the records provided. Our physician reviewer found that the "simple I&D" performed was to extend a prior I&D incision so that the abscess in question could more easily/completely drain. There is no indication that either the abscess, or the I&D, was complicated or multiple. Therefore, the billing of CPT 10061 is not supported.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 pay forthe services (CPT 10061) provided to the enrollee on June 16, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medication Spravato (J3490).You asked the Plan to pre-approvethis medication. You say that you are requesting reconsideration of the Plan's denial as you feel the medication Spravato is an excellent treatment for the enrollee as she has tried tenmedications to help control her depression symptoms without success.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverageof the medication Spravato. Per the Plan's medical policy, the medication Spravato is not covered in patients with current or previous comorbid psychiatric conditions such as bipolar disorder. Additionally, the clinical notes submitted suggest a history of non-adherence to traditional agents due to the potential for weight gain. It is unclear if this patient truly has had an adequate trial of failure of traditional agents for depression.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the medication Spravato. Our physician reviewer found that based on the review of the records provided, it does not appear that this patient has been given an adequate trial of medication or the treatment of antidepressant medication. Additionally, the use of Spravatois not indicated for thetreatment of Bipolar Disorder or a patient with vascular disease.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe medication Spravato (J3490)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra (L8000) and prosthesis (L8030)
You asked the Plan to pre-approve a mastectomy bra and prosthesis. You say that this should be covered. The Plan denied your request. The Plan says these items can be provided by in-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 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 a mastectomy bra (L8000) and prosthesis (L8030)
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that require IRF care. The records do not show you require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medicare coverage criteria are not met. 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.