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

We decided that the Plan does not have to pre-approve Stelara SQ 90mg dosed every 4 weeks (J3357).
You asked the Plan to pre-approve Stelara SQ 90mg dosed every 4 weeks. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Stelara SQ 90mg dosed every 4 weeks. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Stelara SQ 90 mg dosed every 4 weeks is medically reasonable and necessary or safe and effective for the enrollee. The Medicare-approved drug compendia does not support every 4 week dosing of Stelara for Crohn's 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 Stelara SQ 90mg dosed every 4 weeks have not been met. Therefore, we decided that the Plan does not have to pre-approve Stelara SQ 90mg dosed every 4 weeks (J3357).
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 services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a traumatic brain injury. The enrollee subsequently developed pneumonia and sepsis. The enrollee was intubated/ventilated and eventually received a tracheotomy. The enrollee has not tolerated, and is noted to be currently inappropriate for, ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 26, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of services. The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 26, 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 Plan to pre-approve the SNF admission. You say that it is felt that the enrollee would benefit from daily therapy. The Plan denied your request. The Plan says the enrollee's level of function does not require daily skilled therapy services to reach goals.
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 correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee a 77 year old male was hospitalized on 3/10/20 after a fall at home with Rhabdomyolysis. He has required close supervision for bed mobility, contact guard assistance for transfers and ambulation of up to 250 feet on 3/16/2020. Based on review of available records, the patient does not meet criteria for coverage for an SNF admission. The patient is generally medically stable after a fall with no evidence of complex medical issues that require monitoring or need for nursing care. He has no skin care; bowel or bladder care needs. He is independent for mobility. While he may benefit from continuing PT and OT, there is no evidence of need for therapy on a daily basis in an SNF. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 76700) provided to the enrollee on July 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the supporting documentation received does not support CPT 76700.
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 76700 is "Ultrasound, abdominal, real time with image documentation." 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 services at issue in this were not supported. Our physician reviewer found no records were submitted for review. Therefore, there is no evidence to support that the billed services were provided on the date of service in question. 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 for radiology services (CPT 76700) provided to the enrollee on July 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care for sepsis. The member has a very complex medical history but the current hospital stay has additionally been complicated by worsening renal failure and bilateral hydronephrosis requiring replacement of nephrostomy tubes. The member is not required to discharge elsewhere to receive ongoing acute level care. The member requires wound care, therapy and IV antibiotics, which can be safely done in the current acute care setting. Over the past few months, the member has been transferred from an acute care hospital to an LTACH twice. Both times the member bounced back to the acute hospital. It is not clear how the member would benefit from being moved to an LTACH. The review has determined that 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. 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 moderate sedation services (99153) provided on August 3, 2019. You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service. The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Specifically, payment for this service is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on August 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve real-time outpatient cardiac telemetry (93229).
You asked the Plan to pre-approve real-time outpatient cardiac telemetry (93229). You say that the requested real-time outpatient cardiac telemetry is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested real-time outpatient cardiac telemetry.
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 real-time outpatient cardiac telemetry (93229). Our reviewer says that the enrollee does not meet criteria for the requested real-time outpatient cardiac telemetry. Our physician reviewer found the enrollee is with a history of hypertension, diabetes, diverticulosis, nephrolithiasis and paroxysmal atrial fibrillation on anticoagulation. A clinic note dated 02/11/20 documents concern for sleep apnea. There is report of elevated heart rate while sleeping during a sleep study. A request was made for real-time mobile cardiac telemetry. Based on the records the enrollee has known paroxysmal atrial fibrillation on anticoagulation with concern of atrial fibrillation at night during a sleep study that noted high heart rate. In this circumstance if evaluation for continued paroxysmal atrial fibrillation is thought to be medically necessary then a Holter monitor or auto-triggered off-line event recorder should be sufficient to document cardiac rhythm when sleeping. The documentation does not indicate that these off-line devices have been tried, failed or have not been tolerated. Therefore, the documentation does not support the need for real-time outpatient cardiac telemetry and 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 real-time outpatient cardiac telemetry (93229) have not been met. Therefore, we decided that the Plan does not have to pre-approve real-time outpatient cardiac telemetry (93229).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 18, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional physical therapy visits.You asked the Plan to pre-approve4 additional physical therapy visits. You say that you have been having ongoing problems. You say that you have never been denied so early.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 4 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that there are no extenuating deficits which would require 4 additional supervised sessions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the records provided did not indicate a need for frequent or immediate body position changes.
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 a semi-electric hospital bed is not medically reasonable and necessary for the enrollee in this case. The patient's condition does not require positioning of the body in ways not feasible in an ordinary bed. The patient does not require frequent or immediate changes in body position. The patient's condition does not require special attachments that cannot be fixed and used on an ordinary bed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a semi-electric hospital 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on September 18, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 17003 is not supported. 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 17003 is destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion). We find that CPT code 17003 is not supported in the medical record. Specifically, the add-on code was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on September 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
You asked the Plan to pre-approve the PET scan. You say that the clinical information which has now been submitted supports the need for a PET scan. The Plan denied your request. The Plan says there is insufficient clinical information to approve the requested study.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the requested PET scan is not medically reasonable and necessary. Our physician reviewer found the enrollee has had stable lymphadenopathy for 4 years, documented on CT scan. No further imaging is indicated given stability. Even if an indolent lymphoma, a PET scan would unlikely to be of use. There are no findings on history or physical to suggest underlying malignancy. There are no prior biopsies. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on August 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 23655-RT is not supported.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 23655-RT is closed treatment of shoulder dislocation, with manipulation; requiring anesthesia.We find that CPT code 23655-RT is not supported in the medical record. Specifically, there is no documentation that closed treatment of shoulder dislocation with anesthesia was performed for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe services rendered to the enrollee on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.You asked the Planto pre-approveSupartz FX. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided on June 24, 2019. You asked the Plan to pay for the lumbar sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided on June 24, 2019.