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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary, as the enrollee still needs assistance in care. The Plan denied your request. The Plan says custodial care is not a benefit of the plan.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of a cardiac rhythm monitor.You asked the Plan to pre-approvecardiac rhythm monitor. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because an externally worn cardiac event monitor can be used instead of an implantable device, with less risk to the enrollee.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 cardiac rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has a long-standing recurrent syncope and is associated with a normal cardiac examination, normal electrocardiogram (EKG), normal echocardiogram, and normal nuclear stress test. In this circumstance, if evaluation for an arrhythmia were thought to bemedically necessary then external off-line event recording would be safer than an implantable loop recorder and would be effective in identification of cardiac rhythm during symptoms. An implantable loop recorder does not meet Medicare coverage criteria because this test exceeds the enrollee's medical 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 cardiac rhythm monitor have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of a cardiac rhythm monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 enrollee is medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care he may benefit from further PT and OT but does not require an intensive therapy program. IRF admission is not medically necessary based on his current functional status and medical stability 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVenaSeal (36482).You asked the Plan to pre-approveVenaSeal. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's condition is sufficiently treated with compression.The Plan follows Medicare rules. Medicare rules say that treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins may be covered as medically necessary with a documented 3-month trial of conservative therapy including graduated compression stockings, weight reduction, therapeutic leg elevation, and an exercise program, which results in limited alteration/improvementof symptoms or findings without satisfactory endpoint.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 VenaSeal. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found there is no evidence of functionally limiting symptoms and no evidence that there has been a failure of conservative efforts. Additionally, the medical records are not supportive of the medical necessity of the procedure in question. he patient complains of occasional itching on the left lower extremity that has a varicose vein. This has only been noted for the past few months. There are no other associated symptoms. The symptoms are relieved if he wears compression stockings. It is not lifestyle limiting. The patient denies edema. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of VenaSeal have not been met.Therefore, we decided that the Plan does not have to pre-approveVenaSeal (36482).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from September 17, 2019 through October 22, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that he cannot afford these bills. You say that the Plan should help. The Plan denied your request. The Plan says the copayments applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for each Medicare-covered outpatient hospital service form a Tier 1 provider.
The enrollee has been asked to pay a $100 copayment for each for wound debridement visit. The total amount you owe is $600 ($100/visit x 6 visits = $600). Wound debridement falls within the "Outpatient hospital services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided from September 17, 2019 through October 22, 2019.
Your complaint about the cost not being fair is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 it is felt you require IRF care. The Plan denied your request. The Plan says you do not meet criteria for IRF 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee presented to the facility with Bell's palsy with left facial droop and left arm weakness. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive IRF physician or nursing supervision. The patient may benefit and participate from multiple therapies such as PT and OT, however the documentation does not support that this patient requires 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 pre-approve medial branch blocks for the enrollee.
You asked the Plan to pre-approve medial branch blocks. You say that the enrollee has been on hydrocodone for more than 4 weeks without relief. The Plan denied your request. The Plan says the enrollee has not tried conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that medial branch blocks are covered only under certain medical indications.
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 requested services. Our physician reviewer found that the enrollee has chronic neck pain and tenderness over her upper cervical facets. Facet arthropathy is confirmed on MRI. She has not had recent physical therapy or chiropractic therapy. She has not had a trial of NSAIDs. The enrollee has not had an adequate trial of conservative therapy. Therefore, the request is considered not medically reasonable or necessary at this time.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the services are available in-network.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 care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee does need this in order to be able to test more frequently which will allow her to lower her A1C over time. The Plan denied your request. The Plan says that the enrollee has not tested the required amount per day so she cannot be allowed to have the CGM.
The Plan follows Medicare rules. Medicare rules say that while MAXIMUS must consider LCDs, such a determination is not considered binding. The rules say that services that are considered medically necessary can be 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 CGM. Our reviewer says that although the LCD criteria are not met, the evidence suggests that the use of the CGM is medically reasonable and necessary for this enrollee to better manage her medical condition. Our physician reviewer found the enrollee is a female using Humalog 10 units three times daily, plus Lantus 24 units once a day. She has logs showing BGs checks 1-3x/d with standard glucometer; her a1cs have been 7.5-7.8%. She has asthma and hypertension as well. She is followed closely. Since the enrollee does require four shots of insulin per day and is at risk of low blood sugar from this, having a meter that will enable her to more easily comply with 4x/d checking is important. Her treatment plan is for testing four times per day, and the issue is compliance which can be reasonably assisted through the use of the CGM. 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 CGM have been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 a residential treatment program.You asked the Plan to pre-approve a residential treatment program. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says residential treatment services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare has specific coverage criteria for mental health treatment. Residential treatment is not covered.Therefore, we decided that the Plan does not have to pre-approve a residential treatment program.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records submitted do not support the medical necessity of this admission.
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 LTACH. The enrollee has a tracheotomy and is on a ventilator. There is no evidence that the enrollee has tolerated or is amenable to ventilator weaning. Ongoing care in a LTACH is not shown to be medically necessary. The enrollee can then be transferred/discharged to a lower level of care (SNF with vent, LTC facility, ECF, Hospice) for any ongoing long-term care 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee does not have a complex illness that requires long term acute care and daily physician management.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute carehospitals. In this case, ongoing care needs include respiratory support including CPAP, nasal gastric tube suction and care, parenteral nutrition, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 30, 2019. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 on April 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 genetic testing provided on June 10, 2019.
You asked the Plan to pay for Guardant360 testing. You say that this testing was ordering by the enrollee's treating physician as medically necessary and should be covered by the Plan. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not approved for use in any cancer other than non-small cell lung cancer and has no clinical utility in this case.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 is only covered when the enrollee has been diagnosed with advanced NSCLC and meets certain specific criteria. We looked at the file and Medicare rules. This testing was nor ordered for a diagnosis of advanced non-small cell lung cancer, and the record does not show that the enrollee had a diagnosis of advanced non-small cell lung cancer at the time this testing was performed. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 genetic testing provided on June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another 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 ACH for progression to end-stage renal disease. The enrollee has been started on hemodialysis. The enrollee is not intubated/ventilated. 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 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 admission to a long term acute care hospital (LTACH) for the enrollee.