Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure injection.

You asked the Plan to pre-approve Repatha Sure injection. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Repatha Sure injection is not 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-approve Repatha Sure injection.

Benefits for Repatha Sure injection may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health visits (G0299).

You asked the Plan to pre-approve the additional home health visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says 2 additional visits have already been approved. The 7 additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs (e.g. IVs, complex wound care, new illness or injury). As such, the requested additional skilled nursing visits are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor
(K0553) provided on February 13, 2021.
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that you would like
reconsideration because the billed supplies are medically necessary. The Plan denied your request. The Plan
says the documentation does not show that the requested supplies are medically necessary of that the provider
discussed the need for these supplies.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the continuous glucose monitor supply
allowance. Our reviewer says that there is no mention in the records as to why the member needs the requested
supplies or why a glucometer would not suffice. Our physician reviewer found the records do not show that the
member is adjusting their insulin based on blood glucose levels. Additionally, the form states that the member
is checking their blood glucose and taking insulin, but the medical documentation does not support this.
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 continuous glucose monitor supply allowance have not been met. Therefore,
we decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor
(K0553) provided on February 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral cervical facet joint radiofrequency ablation
(RFA) procedure.
You asked the Plan to pre-approve a bilateral cervical facet joint radiofrequency ablation (RFA) procedure.
You say that the requested bilateral cervical facet joint RFA procedure is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet criteria for the requested bilateral cervical facet joint
radiofrequency ablation (RFA) procedure.
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 bilateral cervical facet joint radiofrequency ablation (RFA) procedure. Our reviewer says that the enrollee does not meet criteria for the
requested bilateral cervical facet joint radiofrequency ablation (RFA) procedure. Our physician reviewer found
the request does not meet the LCD criteria because there has been greater than 2 years of time from the prior RFA procedure. There is no documentation of the response from the prior RFA and no documentation of a recent repeat diagnostic blocks being performed. The enrollee has multifactorial sources of cervical pain
including multi-level disc herniations with noted radiating pain and fibromyalgia. The requested procedure is deemed not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a bilateral cervical facet joint radiofrequency ablation (RFA) procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral cervical facet joint
radiofrequency ablation (RFA) procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 20931, 20936, 22633, 63047, 63048), for the enrollee.
You asked the Plan to pre-approve the spinal surgery. You say that the enrollee is unable to take nonsteroidal anti-inflammatory drugs (NSAIDs) due to their kidney function and gets severe nausea with prescription pain medications. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee has had three straight months of standard treatment methods ordered by their doctor with either of the following: 1) drugs for pain and/or swelling and/or 2) therapy (physical therapy) ordered by the enrollee's doctor. The Plan states the requested surgery is not supported before a trial of treatment, and therefore the appeal remains denied at this time.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal surgery not met. There is no recent trial of physical therapy for back pain.
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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 20931, 20936, 22633, 63047, 63048), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for knee arthroscopy (CPT code 27447), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the health plan's denial should be upheld. The enrollee is to undergo a procedure that is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities pre-procedure. The enrollee should present for, undergo and be monitored following the procedure as an outpatient. Should any compilations arise that necessitate a prolonged stay (i.e. two midnights), the enrollee can be converted to inpatient status, at that time, under the two-midnight rule. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for knee arthroscopy (CPT code 27447), for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
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 the requested SNF care is medically necessary. Our physician reviewer found the enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below his baseline and has not yet been shown to have reached a new plateau in function. Daily skilled 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. The Plan denied your request. The Plan says that the medical records do not support the need for continued care to receive inpatient (hospital) psychiatric services.

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 inpatient psychiatric hospital services. Our reviewer says that the records provided for the admission of this patient does meet the criteria for continued acute inpatient mental health treatment. Our physician reviewer found this enrollee does appear to have auditory hallucinations. Our reviewer also found that active treatment is taking place and the requested services are expected to improve the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric services.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95955, 95908, 95937) provided February 16, 2021.
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 codes 95955, 95908 and 95937 are Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery), Nerve conduction studies; 3-4 studies, and neuromuscular junction testing.
We find that CPT codes 95955, 95908 and 95937 are not supported in the medical record. Specifically, the medical records provided do not include sufficient documentation to validate that an Electroencephalogram was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. The medical records submitted document Train of Four testing, which does not meet the coding definition of CPT 95937. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95955, 95908, 95937) provided February 16, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve permanent placement of a peripheral sacral nerve stimulator for treatment of fecal incontinence.

You asked the Plan to pre-approve the sacral nerve stimulator placement. You say that this is a medically necessary procedure as maximal medical management has not controlled her symptoms. The Plan denied your request. The Plan says that there has not been a trial of other treatments as required.

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 sacral nerve stimulator placement. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in the absence of a national or local coverage determination, the Social Security Act, Section 1862 (a)1(A) defines medically necessary and reasonable services. UpToDate states that sacral nerve stimulation is indicated for patients who are either not candidates for biofeedback or sphincteroplasty. 

In this case, the record indicates that the enrollee has had a sphincterotomy and has rectal pain and incontinence. The record indicates that the enrollee has 4 episodes of incontinence per day. The enrollee has undergone manometry that indicates that the enrollee has decreased resting and squeeze pressures. The record indicates that the enrollee has failed conservative measures. Ultrasound demonstrates no sphincteric defect. The elements of the coverage criteria are satisfied. 

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 sacral nerve stimulator placement have been met. Therefore, we decided that the Plan has to pre-approve permanent placement of a peripheral sacral nerve stimulator for treatment of fecal incontinence.

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 pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that currently the enrollee does meet CMS LTAC admission criteria and his ongoing medical care warrants an LTAC level of care to achieve a safe and sustainable discharge, per CMS guidelines. The Plan denied your request. The Plan says it is not medically necessary to be in an LTACH in place of an acute care hospital.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting (92310) fundus photography with interpretation and report (92250) contact lens, PMMA (V2500) provided May 3, 2021.

You asked the Plan to pay for the vision services. You say that you are appealing this decision. You request contact lens until you can get cataract surgery. You live alone so your correct vision is necessary. The Plan denied your request. The Plan says the maximum allowed benefit amount has been exceeded.

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 all costs over the $100 allowance amount.

You have been asked to pay $137.00 for the vision services. The total billed amount was $316. The plan paid $115 and the total $100 allowed benefit amount was applied. The vision services fall within the Vision 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 pay for contact lens fitting (92310) fundus photography with interpretation and report (92250) contact lens, PMMA (V2500) provided May 3, 2021.