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

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT code(s) 22869 and 22870).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT code(s) 22869 and 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pegfilgrastim (Neulasta).

You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says this regimen is associated with a low risk of febrile neutropenia and the National Comprehensive Cancer Network (NCCN) recommends no routine prophylactic growth factor (Pegfilgrastim) in this setting.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Neulasta. Our reviewer says that Pegfilgrastim (Neulasta) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Pegfilgrastim (J2505) is not FDA-approved for the enrollee's diagnosis. The recommendations are to hold the drug until neutropenia recovers. Our reviewer found that the use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the use is not listed as not indicated, not supported, or not recommended in any of the compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Pegfilgrastim (Neulasta).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section 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 correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is required to safely and effectively provide medically necessary and reasonable treatment. daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 waive the copayment for the diagnostic eye exam or pay for the retinal imaging.

You asked the Plan to waive the copayment for the diagnostic eye exam and pay for the retinal imaging. You say that you did not understand the preferred provider was a group of doctors. The Plan denied your request. The Plan says the exam was billed as a diagnostic eye exam and the retinal imaging was billed as routine by an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers refraction when provided by the preferred providers.

We looked at the file and the Plan's rules. The exam was a diagnostic exam and the refraction was not provided in-network. Based on this information, we decided that the Plan does not have to waive the copayment for the diagnostic eye exam or pay for the retinal imaging.
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 rules for IRF care have not been 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable oxygen supplies (E0443).

You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you have not had to pay a coinsurance or copayment for this item in 4 years. The Plan denied your request. The Plan says oxygen equipment requires a 20% coinsurance. According to the information provided, you reached your capped rental agreement that was signed in 2017. This claim processed correctly.

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 20% coinsurance for Durable Medical Equipment (DME) and related supplies.

You have been asked to pay $13.28 for the oxygen supplies. The Plan's allowed amount for this item is $66.38 ($66.38 x 20% = $13.28). Oxygen supplies fall within the Durable Medical Equipment (DME) and related supplies benefit category. 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 coinsurance for the portable oxygen supplies (E0443).
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure, pulmonary edema and knee pain. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).

You asked the Plan to pre-approve a transforaminal epidural. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 a transforaminal epidural. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found this request exceeds the LCD limit of three Epidural steroid injections within a six month period. Therefore, the request is considered 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 transforaminal epidural have not been met. Specifically, records indicate you have received three epidural injections within a six month time frame. This means you have exceeded the limit given for epidurals, and therefore, the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit.
You asked the Plan to waive the copayment for the ER visit. You say that the services were too expensive for
was performed. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $120
copayment for emergency care.
You have been asked to pay a $120 copayment for the ER visit. This visit falls within the emergency care
benefit category. 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 ER visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health treatment to be provided by the requested provider. You asked the Plan to pre-approve the mental health treatment. You say that you need to see this provider to transition your care to an in-network provider. You say that it is unfair to be taken away from someone that you have built a relationship/trust with and this provider is helping you. The Plan denied your request. The Plan says this provider has opted out of the Medicare network.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve mental health treatment to be provided by the requested provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve wound excision (15002),

You asked the Plan to pre-approve the wound excision. You say that you would like reconsideration because you are experiencing pain and discomfort. The Plan denied your request. The Plan says that the requested service is cosmetic.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wound excision. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the lesion is symptomatic, causing the member pain and discomfort.

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 wound excision have been met. Therefore, we decided that the Plan has to pre-approve wound excision (15002).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services at DRG 871 provided from May
24, 2019, through May 31, 2019.
You asked the Plan to pay for DRG 871. You say that The Plan denied your request. The Plan says there was
insufficient clinical evidence and supportive documentation in the records available for review to substantiate
the coding of this condition.
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. DRG 871 is defined as Septicemia
or Severe Sepsis without MV >96 Hours with MCC.
In this case, you billed the services provided May 24, 2019, through May 31, 2019 with DRG 871. 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 DRG 871. Our reviewer says that DRG 871 is not
supported by the medical record. Our physician reviewer found though sepsis was documented by the
physician, there was insufficient clinical evidence and supportive documentation in the records available for
review to substantiate the coding of this condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate DRG 871. Therefore, we decided that the Plan does not have to pay for
inpatient hospital services at DRG 871 provided from May 24, 2019, through May 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or certified nurse assistant services provided from August 16, 2020, to September 23, 2020. You asked the Plan to pay for the HHA or certified nurse assistant services. You say that you were not able to be released from the hospital until you had 24 hour care. The Plan denied your request. The Plan says you received home health aide services from a provider who is not under contract with the Health Plan, and is not certified for Medicare. The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or certified nurse assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the HHA or certified nurse assistant services provided from August 16, 2020, to
September 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve PTNS.

You asked the Plan to pre-approve the PTNS. You say that you would like reconsideration because the member has not received all 12 months worth of treatments. The Plan denied your request. The Plan says that the member has completed their initial sessions and the remaining one year treatment.

The Plan follows Medicare rules. Medicare rules say that PTNS standard treatment regimen (30-minute sessions given weekly for 12 weeks) will be covered for treatment of OAB symptoms for patients either refractory or intolerant to standard anti-cholinergic drug 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 the PTNS. Our reviewer says that three additional treatments are appropriate and indicated. Our physician reviewer found the standard treatment regimen includes 12 monthly treatments and the records indicate that only 9 treatments have been given. 

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 PTNS have been met. Therefore, we decided that the Plan has to pre-approve PTNS.

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.